{"id":2,"date":"2017-05-10T15:29:13","date_gmt":"2017-05-10T13:29:13","guid":{"rendered":"https:\/\/monorthosurleplateau.ca\/questionnaires\/?page_id=2"},"modified":"2025-07-02T20:10:56","modified_gmt":"2025-07-02T18:10:56","slug":"questionnairemedical","status":"publish","type":"page","link":"https:\/\/monorthosurleplateau.ca\/questionnaires\/questionnairemedical\/","title":{"rendered":"Questionnaire m\u00e9dical"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-12\" src=\"https:\/\/monorthosurleplateau.ca\/questionnaires\/wp-content\/uploads\/2017\/05\/logo.jpg\" alt=\"\" width=\"272\" height=\"139\" \/><\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/questionnaires\/wp-json\/wp\/v2\/pages\/2#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<h3 class=\"gf_progressbar_title\">\u00c9tape <span class='gf_step_current_page'>1<\/span> sur <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_0' style='width:0%; color:#ffffff; background-color:#7991b7;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_150\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">QUESTIONNAIRE M\u00c9DICAL ET DENTAIRE<\/h2><div class='gsection_description' id='gfield_description_1_150'>Le dossier dentaire est constitu\u00e9 dans le cadre des soins qui seront prodigu\u00e9s : il est prot\u00e9g\u00e9 par la loi et\nle secret professionnel. Il est conserv\u00e9 au cabinet et seul l'orthodontiste et son personnel y ont acc\u00e8s.\nLe patient y a aussi un droit d'acc\u00e8s et de rectification.<\/div><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-name gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Renseignement sur le patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>Nom du patient<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom du patient<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sexe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_2'>\n\t\t\t<li class='gchoice gchoice_1_2_0'>\n\t\t\t\t<input name='input_2' type='radio' value='M'  id='choice_1_2_0'    \/>\n\t\t\t\t<label for='choice_1_2_0' id='label_1_2_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_2_1'>\n\t\t\t\t<input name='input_2' type='radio' value='F'  id='choice_1_2_1'    \/>\n\t\t\t\t<label for='choice_1_2_1' id='label_1_2_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_164\" class=\"gfield gfield--type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_164'>R\u00e9f\u00e9r\u00e9 par<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_1_164' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-address gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_1_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_3_1' id='input_1_3_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse et appartement<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_3_3' id='input_1_3_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_3_4_container' >\n                                        <select name='input_3.4' id='input_1_3_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' selected='selected'>Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_1_3_4' id='input_1_3_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_1_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_3_5' id='input_1_3_5_label' class='gform-field-label gform-field-label--type-sub '>Code Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_1_3_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_163\" class=\"gfield gfield--type-phone gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_163'>T\u00e9l\u00e9phone domicile<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_163' id='input_1_163' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>T\u00e9l\u00e9phone cellulaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_1_5' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_172\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_172'>T\u00e9l\u00e9phone bureau<\/label><div class='ginput_container ginput_container_phone'><input name='input_172' id='input_1_172' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_173\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_173'>Poste<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_1_173' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-email gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_1_8' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous une assurance dentaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_9'>\n\t\t\t<li class='gchoice gchoice_1_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Oui'  id='choice_1_9_0'    \/>\n\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Non'  id='choice_1_9_1'    \/>\n\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_142\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Confirmation de rendez-vous par<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_142'>\n\t\t\t<li class='gchoice gchoice_1_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Domicile'  id='choice_1_142_0'    \/>\n\t\t\t\t<label for='choice_1_142_0' id='label_1_142_0' class='gform-field-label gform-field-label--type-inline'>Domicile<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='Bureau'  id='choice_1_142_1'    \/>\n\t\t\t\t<label for='choice_1_142_1' id='label_1_142_1' class='gform-field-label gform-field-label--type-inline'>Bureau<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_142_2'>\n\t\t\t\t<input name='input_142' type='radio' value='Cellulaire'  id='choice_1_142_2'    \/>\n\t\t\t\t<label for='choice_1_142_2' id='label_1_142_2' class='gform-field-label gform-field-label--type-inline'>Cellulaire<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_142_3'>\n\t\t\t\t<input name='input_142' type='radio' value='Courriel'  id='choice_1_142_3'    \/>\n\t\t\t\t<label for='choice_1_142_3' id='label_1_142_3' class='gform-field-label gform-field-label--type-inline'>Courriel<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_1_12' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_1_12_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_12_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_12' class='gform_hidden' value='https:\/\/monorthosurleplateau.ca\/questionnaires\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-text gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Num\u00e9ro d\u2019assurance maladie<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>En cas d&#039;urgence, contacter<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_1_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>T\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Poste<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Moins de 14 ans, inscrire le nom du parent\/tuteur<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sp\u00e9cifier<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_18'>\n\t\t\t<li class='gchoice gchoice_1_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Parent'  id='choice_1_18_0'    \/>\n\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='Tuteur'  id='choice_1_18_1'    \/>\n\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>Tuteur<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Raisons de la consultation<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_23'><li class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Manque d&#039;espace'  id='choice_1_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>Manque d'espace<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Esth\u00e9tique du sourire'  id='choice_1_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2' class='gform-field-label gform-field-label--type-inline'>Esth\u00e9tique du sourire<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Dents incluses'  id='choice_1_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_3' id='label_1_23_3' class='gform-field-label gform-field-label--type-inline'>Dents incluses<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Orthodontie fonctionnelle'  id='choice_1_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_4' id='label_1_23_4' class='gform-field-label gform-field-label--type-inline'>Orthodontie fonctionnelle<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='R\u00e9habilitation'  id='choice_1_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_5' id='label_1_23_5' class='gform-field-label gform-field-label--type-inline'>R\u00e9habilitation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_23_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.6' type='checkbox'  value='Traitement Invisalign'  id='choice_1_23_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_6' id='label_1_23_6' class='gform-field-label gform-field-label--type-inline'>Traitement Invisalign<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_23_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.7' type='checkbox'  value='Maloclusion'  id='choice_1_23_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_7' id='label_1_23_7' class='gform-field-label gform-field-label--type-inline'>Maloclusion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_23_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.8' type='checkbox'  value='Douleur'  id='choice_1_23_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_8' id='label_1_23_8' class='gform-field-label gform-field-label--type-inline'>Douleur<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_23_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.9' type='checkbox'  value='Autre'  id='choice_1_23_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_9' id='label_1_23_9' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_151\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">RESPONSABLE DES HONORAIRES<\/div><\/li><li id=\"field_1_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Responsable des honoraires<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_25'><li class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Patient'  id='choice_1_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>Patient<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Autre responsable'  id='choice_1_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2' class='gform-field-label gform-field-label--type-inline'>Autre responsable<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_27\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Nom du responsable<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Coordonn\u00e9es du responsable<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_26'><li class='gchoice gchoice_1_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='M\u00eame que le patient'  id='choice_1_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1' class='gform-field-label gform-field-label--type-inline'>M\u00eame que le patient<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_28\" class=\"gfield gfield--type-address gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_28' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_28_1_container' >\n                                        <input type='text' name='input_28.1' id='input_1_28_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_28_1' id='input_1_28_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse et appartement<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_28_3_container' >\n                                    <input type='text' name='input_28.3' id='input_1_28_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_28_3' id='input_1_28_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_28_4_container' >\n                                        <select name='input_28.4' id='input_1_28_4'     aria-required='false'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' selected='selected'>Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_1_28_4' id='input_1_28_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_28_5_container' >\n                                    <input type='text' name='input_28.5' id='input_1_28_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_28_5' id='input_1_28_5_label' class='gform-field-label gform-field-label--type-sub '>Code Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_28.6' id='input_1_28_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_29\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>T\u00e9l\u00e9phone domicile<\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_1_29' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_30\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>T\u00e9l\u00e9phone cellulaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_1_30' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_31\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>T\u00e9l\u00e9phone bureau<\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_1_31' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>Poste<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_1_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_33\" class=\"gfield gfield--type-email gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_1_33' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_159' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-159' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_156\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">ANT\u00c9C\u00c9DENTS DENTAIRES<\/div><\/li><li id=\"field_1_106\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Derni\u00e8re visite<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_106'>\n\t\t\t<li class='gchoice gchoice_1_106_0'>\n\t\t\t\t<input name='input_106' type='radio' value='0 \u00e0 6 mois'  id='choice_1_106_0'    \/>\n\t\t\t\t<label for='choice_1_106_0' id='label_1_106_0' class='gform-field-label gform-field-label--type-inline'>0 \u00e0 6 mois<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_106_1'>\n\t\t\t\t<input name='input_106' type='radio' value='6 \u00e0 12 mois'  id='choice_1_106_1'    \/>\n\t\t\t\t<label for='choice_1_106_1' id='label_1_106_1' class='gform-field-label gform-field-label--type-inline'>6 \u00e0 12 mois<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_106_2'>\n\t\t\t\t<input name='input_106' type='radio' value='+ de 12 mois'  id='choice_1_106_2'    \/>\n\t\t\t\t<label for='choice_1_106_2' id='label_1_106_2' class='gform-field-label gform-field-label--type-inline'>+ de 12 mois<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_107\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_107'>Quel est le nom du dentiste actuel<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_1_107' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_171\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sommes-nous autoris\u00e9s \u00e0 lui partager les rapports d&#039;observations, photos et radiographies<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_171'>\n\t\t\t<li class='gchoice gchoice_1_171_0'>\n\t\t\t\t<input name='input_171' type='radio' value='Oui'  id='choice_1_171_0'    \/>\n\t\t\t\t<label for='choice_1_171_0' id='label_1_171_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_171_1'>\n\t\t\t\t<input name='input_171' type='radio' value='Non'  id='choice_1_171_1'    \/>\n\t\t\t\t<label for='choice_1_171_1' id='label_1_171_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_157\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">AVEZ-VOUS D\u00c9J\u00c0 EU DES TRAITEMENTS DENTAIRES TELS QUE<\/div><\/li><li id=\"field_1_110\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Radiographies dentaires<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_110'>\n\t\t\t<li class='gchoice gchoice_1_110_0'>\n\t\t\t\t<input name='input_110' type='radio' value='Oui'  id='choice_1_110_0'    \/>\n\t\t\t\t<label for='choice_1_110_0' id='label_1_110_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_110_1'>\n\t\t\t\t<input name='input_110' type='radio' value='Non'  id='choice_1_110_1'    \/>\n\t\t\t\t<label for='choice_1_110_1' id='label_1_110_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_147\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Traitement des gencives<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_147'>\n\t\t\t<li class='gchoice gchoice_1_147_0'>\n\t\t\t\t<input name='input_147' type='radio' value='Oui'  id='choice_1_147_0'    \/>\n\t\t\t\t<label for='choice_1_147_0' id='label_1_147_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_147_1'>\n\t\t\t\t<input name='input_147' type='radio' value='Non'  id='choice_1_147_1'    \/>\n\t\t\t\t<label for='choice_1_147_1' id='label_1_147_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_111\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Traitement d\u2019orthodontie<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_111'>\n\t\t\t<li class='gchoice gchoice_1_111_0'>\n\t\t\t\t<input name='input_111' type='radio' value='Oui'  id='choice_1_111_0'    \/>\n\t\t\t\t<label for='choice_1_111_0' id='label_1_111_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_111_1'>\n\t\t\t\t<input name='input_111' type='radio' value='Non'  id='choice_1_111_1'    \/>\n\t\t\t\t<label for='choice_1_111_1' id='label_1_111_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_112\" class=\"gfield gfield--type-text gf_fourth_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_112'>Si oui, quel est le nom de l&#039;orthodontiste<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_1_112' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_113\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Obturation (r\u00e9paration)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_113'>\n\t\t\t<li class='gchoice gchoice_1_113_0'>\n\t\t\t\t<input name='input_113' type='radio' value='Oui'  id='choice_1_113_0'    \/>\n\t\t\t\t<label for='choice_1_113_0' id='label_1_113_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_113_1'>\n\t\t\t\t<input name='input_113' type='radio' value='Non'  id='choice_1_113_1'    \/>\n\t\t\t\t<label for='choice_1_113_1' id='label_1_113_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_114\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Couronne et\/ou pont<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_114'>\n\t\t\t<li class='gchoice gchoice_1_114_0'>\n\t\t\t\t<input name='input_114' type='radio' value='Oui'  id='choice_1_114_0'    \/>\n\t\t\t\t<label for='choice_1_114_0' id='label_1_114_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_114_1'>\n\t\t\t\t<input name='input_114' type='radio' value='Non'  id='choice_1_114_1'    \/>\n\t\t\t\t<label for='choice_1_114_1' id='label_1_114_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_115\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Traitement de canal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_115'>\n\t\t\t<li class='gchoice gchoice_1_115_0'>\n\t\t\t\t<input name='input_115' type='radio' value='Oui'  id='choice_1_115_0'    \/>\n\t\t\t\t<label for='choice_1_115_0' id='label_1_115_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_115_1'>\n\t\t\t\t<input name='input_115' type='radio' value='Non'  id='choice_1_115_1'    \/>\n\t\t\t\t<label for='choice_1_115_1' id='label_1_115_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_116\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Traitement de chirurgie buccale ou extraction<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_116'>\n\t\t\t<li class='gchoice gchoice_1_116_0'>\n\t\t\t\t<input name='input_116' type='radio' value='Oui'  id='choice_1_116_0'    \/>\n\t\t\t\t<label for='choice_1_116_0' id='label_1_116_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_116_1'>\n\t\t\t\t<input name='input_116' type='radio' value='Non'  id='choice_1_116_1'    \/>\n\t\t\t\t<label for='choice_1_116_1' id='label_1_116_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_117\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Implant dentaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_117'>\n\t\t\t<li class='gchoice gchoice_1_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='Oui'  id='choice_1_117_0'    \/>\n\t\t\t\t<label for='choice_1_117_0' id='label_1_117_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='Non'  id='choice_1_117_1'    \/>\n\t\t\t\t<label for='choice_1_117_1' id='label_1_117_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_118\" class=\"gfield gfield--type-radio gfield--type-choice gf_second_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Proth\u00e8ses compl\u00e8te et\/ou partielle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_118'>\n\t\t\t<li class='gchoice gchoice_1_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='Oui'  id='choice_1_118_0'    \/>\n\t\t\t\t<label for='choice_1_118_0' id='label_1_118_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='Non'  id='choice_1_118_1'    \/>\n\t\t\t\t<label for='choice_1_118_1' id='label_1_118_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_119\" class=\"gfield gfield--type-radio gfield--type-choice gf_third_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Les amygdales ont-elles \u00e9t\u00e9 enlev\u00e9es<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_119'>\n\t\t\t<li class='gchoice gchoice_1_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='Oui'  id='choice_1_119_0'    \/>\n\t\t\t\t<label for='choice_1_119_0' id='label_1_119_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_119_1'>\n\t\t\t\t<input name='input_119' type='radio' value='Non'  id='choice_1_119_1'    \/>\n\t\t\t\t<label for='choice_1_119_1' id='label_1_119_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_120\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous des craquements \u00e0 l&#039;articulation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_120'>\n\t\t\t<li class='gchoice gchoice_1_120_0'>\n\t\t\t\t<input name='input_120' type='radio' value='Oui'  id='choice_1_120_0'    \/>\n\t\t\t\t<label for='choice_1_120_0' id='label_1_120_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_120_1'>\n\t\t\t\t<input name='input_120' type='radio' value='Non'  id='choice_1_120_1'    \/>\n\t\t\t\t<label for='choice_1_120_1' id='label_1_120_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_121\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous une d\u00e9viation de la cloison nasale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_121'>\n\t\t\t<li class='gchoice gchoice_1_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Oui'  id='choice_1_121_0'    \/>\n\t\t\t\t<label for='choice_1_121_0' id='label_1_121_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='Non'  id='choice_1_121_1'    \/>\n\t\t\t\t<label for='choice_1_121_1' id='label_1_121_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_122\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous de la difficult\u00e9 \u00e0 respirer par le nez<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_122'>\n\t\t\t<li class='gchoice gchoice_1_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Oui'  id='choice_1_122_0'    \/>\n\t\t\t\t<label for='choice_1_122_0' id='label_1_122_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='Non'  id='choice_1_122_1'    \/>\n\t\t\t\t<label for='choice_1_122_1' id='label_1_122_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_123\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 eu un accident \u00e0 la t\u00eate ou au visage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_123'>\n\t\t\t<li class='gchoice gchoice_1_123_0'>\n\t\t\t\t<input name='input_123' type='radio' value='Oui'  id='choice_1_123_0'    \/>\n\t\t\t\t<label for='choice_1_123_0' id='label_1_123_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_123_1'>\n\t\t\t\t<input name='input_123' type='radio' value='Non'  id='choice_1_123_1'    \/>\n\t\t\t\t<label for='choice_1_123_1' id='label_1_123_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_158\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">HABITUDES ORALES<\/div><\/li><li id=\"field_1_124\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Succion d&#039;un doigt<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_124'>\n\t\t\t<li class='gchoice gchoice_1_124_0'>\n\t\t\t\t<input name='input_124' type='radio' value='Oui'  id='choice_1_124_0'    \/>\n\t\t\t\t<label for='choice_1_124_0' id='label_1_124_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_124_1'>\n\t\t\t\t<input name='input_124' type='radio' value='Non'  id='choice_1_124_1'    \/>\n\t\t\t\t<label for='choice_1_124_1' id='label_1_124_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_126\" class=\"gfield gfield--type-radio gfield--type-choice gf_second_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Propulsion de la langue<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_126'>\n\t\t\t<li class='gchoice gchoice_1_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Oui'  id='choice_1_126_0'    \/>\n\t\t\t\t<label for='choice_1_126_0' id='label_1_126_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='Non'  id='choice_1_126_1'    \/>\n\t\t\t\t<label for='choice_1_126_1' id='label_1_126_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_127\" class=\"gfield gfield--type-radio gfield--type-choice gf_third_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Respiration buccale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_127'>\n\t\t\t<li class='gchoice gchoice_1_127_0'>\n\t\t\t\t<input name='input_127' type='radio' value='Oui'  id='choice_1_127_0'    \/>\n\t\t\t\t<label for='choice_1_127_0' id='label_1_127_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_127_1'>\n\t\t\t\t<input name='input_127' type='radio' value='Non'  id='choice_1_127_1'    \/>\n\t\t\t\t<label for='choice_1_127_1' id='label_1_127_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_128\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Trouble de diction<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_128'>\n\t\t\t<li class='gchoice gchoice_1_128_0'>\n\t\t\t\t<input name='input_128' type='radio' value='Oui'  id='choice_1_128_0'    \/>\n\t\t\t\t<label for='choice_1_128_0' id='label_1_128_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_128_1'>\n\t\t\t\t<input name='input_128' type='radio' value='Non'  id='choice_1_128_1'    \/>\n\t\t\t\t<label for='choice_1_128_1' id='label_1_128_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_129\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Mordillement des l\u00e8vres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_129'>\n\t\t\t<li class='gchoice gchoice_1_129_0'>\n\t\t\t\t<input name='input_129' type='radio' value='Oui'  id='choice_1_129_0'    \/>\n\t\t\t\t<label for='choice_1_129_0' id='label_1_129_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_129_1'>\n\t\t\t\t<input name='input_129' type='radio' value='Non'  id='choice_1_129_1'    \/>\n\t\t\t\t<label for='choice_1_129_1' id='label_1_129_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_130\" class=\"gfield gfield--type-radio gfield--type-choice gf_second_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rongement des ongles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_130'>\n\t\t\t<li class='gchoice gchoice_1_130_0'>\n\t\t\t\t<input name='input_130' type='radio' value='Oui'  id='choice_1_130_0'    \/>\n\t\t\t\t<label for='choice_1_130_0' id='label_1_130_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_130_1'>\n\t\t\t\t<input name='input_130' type='radio' value='Non'  id='choice_1_130_1'    \/>\n\t\t\t\t<label for='choice_1_130_1' id='label_1_130_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_131\" class=\"gfield gfield--type-radio gfield--type-choice gf_third_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Serrement des dents<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_131'>\n\t\t\t<li class='gchoice gchoice_1_131_0'>\n\t\t\t\t<input name='input_131' type='radio' value='Oui'  id='choice_1_131_0'    \/>\n\t\t\t\t<label for='choice_1_131_0' id='label_1_131_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_131_1'>\n\t\t\t\t<input name='input_131' type='radio' value='Non'  id='choice_1_131_1'    \/>\n\t\t\t\t<label for='choice_1_131_1' id='label_1_131_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_132\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Grincement des dents<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_132'>\n\t\t\t<li class='gchoice gchoice_1_132_0'>\n\t\t\t\t<input name='input_132' type='radio' value='Oui'  id='choice_1_132_0'    \/>\n\t\t\t\t<label for='choice_1_132_0' id='label_1_132_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_132_1'>\n\t\t\t\t<input name='input_132' type='radio' value='Non'  id='choice_1_132_1'    \/>\n\t\t\t\t<label for='choice_1_132_1' id='label_1_132_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_133\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Saignement des gencives<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_133'>\n\t\t\t<li class='gchoice gchoice_1_133_0'>\n\t\t\t\t<input name='input_133' type='radio' value='Oui'  id='choice_1_133_0'    \/>\n\t\t\t\t<label for='choice_1_133_0' id='label_1_133_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_133_1'>\n\t\t\t\t<input name='input_133' type='radio' value='Non'  id='choice_1_133_1'    \/>\n\t\t\t\t<label for='choice_1_133_1' id='label_1_133_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_134\" class=\"gfield gfield--type-radio gfield--type-choice gf_second_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Difficult\u00e9 \u00e0 ouvrir la bouche<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_134'>\n\t\t\t<li class='gchoice gchoice_1_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Oui'  id='choice_1_134_0'    \/>\n\t\t\t\t<label for='choice_1_134_0' id='label_1_134_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='Non'  id='choice_1_134_1'    \/>\n\t\t\t\t<label for='choice_1_134_1' id='label_1_134_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_149\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Maux de t\u00eate fr\u00e9quents<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_149'>\n\t\t\t<li class='gchoice gchoice_1_149_0'>\n\t\t\t\t<input name='input_149' type='radio' value='Oui'  id='choice_1_149_0'    \/>\n\t\t\t\t<label for='choice_1_149_0' id='label_1_149_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_149_1'>\n\t\t\t\t<input name='input_149' type='radio' value='Non'  id='choice_1_149_1'    \/>\n\t\t\t\t<label for='choice_1_149_1' id='label_1_149_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_135\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ronflez-vous<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_135'>\n\t\t\t<li class='gchoice gchoice_1_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='Oui'  id='choice_1_135_0'    \/>\n\t\t\t\t<label for='choice_1_135_0' id='label_1_135_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='Non'  id='choice_1_135_1'    \/>\n\t\t\t\t<label for='choice_1_135_1' id='label_1_135_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_174\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Souffrez-vous ou pensez-vous souffrir d\u2019apn\u00e9e du sommeil<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_174'>\n\t\t\t<li class='gchoice gchoice_1_174_0'>\n\t\t\t\t<input name='input_174' type='radio' value='Oui'  id='choice_1_174_0'    \/>\n\t\t\t\t<label for='choice_1_174_0' id='label_1_174_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_174_1'>\n\t\t\t\t<input name='input_174' type='radio' value='Non'  id='choice_1_174_1'    \/>\n\t\t\t\t<label for='choice_1_174_1' id='label_1_174_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_137\" class=\"gfield gfield--type-text gf_third_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_137'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_1_137' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_136\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Jouez-vous d&#039;un instrument de musique<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_136'>\n\t\t\t<li class='gchoice gchoice_1_136_0'>\n\t\t\t\t<input name='input_136' type='radio' value='Oui'  id='choice_1_136_0'    \/>\n\t\t\t\t<label for='choice_1_136_0' id='label_1_136_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_136_1'>\n\t\t\t\t<input name='input_136' type='radio' value='Non'  id='choice_1_136_1'    \/>\n\t\t\t\t<label for='choice_1_136_1' id='label_1_136_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_175\" class=\"gfield gfield--type-text gf_third_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_175'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_1_175' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_161' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_1_161' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-161' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_152\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">ANT\u00c9C\u00c9DENTS M\u00c9DICAUX<\/div><\/li><li id=\"field_1_39\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00cates-vous actuellement sous les soins d\u2019un m\u00e9decin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_39'>\n\t\t\t<li class='gchoice gchoice_1_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Oui'  id='choice_1_39_0'    \/>\n\t\t\t\t<label for='choice_1_39_0' id='label_1_39_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='Non'  id='choice_1_39_1'    \/>\n\t\t\t\t<label for='choice_1_39_1' id='label_1_39_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_35\" class=\"gfield gfield--type-text gf_second_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-text gf_third_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Nom du m\u00e9decin<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_40\" class=\"gfield gfield--type-phone gf_fourth_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>T\u00e9l\u00e9phone du m\u00e9decin<\/label><div class='ginput_container ginput_container_phone'><input name='input_40' id='input_1_40' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_41\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00cates-vous actuellement sous les soins d\u2019un th\u00e9rapeute, psychot\u00e9rapeute, ost\u00e9opathe, posturologue, physioth\u00e9rapeute ou autre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_41'>\n\t\t\t<li class='gchoice gchoice_1_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Oui'  id='choice_1_41_0'    \/>\n\t\t\t\t<label for='choice_1_41_0' id='label_1_41_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='Non'  id='choice_1_41_1'    \/>\n\t\t\t\t<label for='choice_1_41_1' id='label_1_41_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_42\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_43\" class=\"gfield gfield--type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>Indiquer tous les m\u00e9dicaments (incluant anovulants et hormones) pris en ce moment ou au cours des 12 derniers mois<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_44\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Prenez-vous des produits naturels ou hom\u00e9opathiques<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_44'>\n\t\t\t<li class='gchoice gchoice_1_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Oui'  id='choice_1_44_0'    \/>\n\t\t\t\t<label for='choice_1_44_0' id='label_1_44_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='Non'  id='choice_1_44_1'    \/>\n\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_45\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_46\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous eu une fluctuation significative de votre masse corporelle dernierement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_46'>\n\t\t\t<li class='gchoice gchoice_1_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Oui'  id='choice_1_46_0'    \/>\n\t\t\t\t<label for='choice_1_46_0' id='label_1_46_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='Non'  id='choice_1_46_1'    \/>\n\t\t\t\t<label for='choice_1_46_1' id='label_1_46_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_47\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00cates-vous enceinte<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_47'>\n\t\t\t<li class='gchoice gchoice_1_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Oui'  id='choice_1_47_0'    \/>\n\t\t\t\t<label for='choice_1_47_0' id='label_1_47_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='Non'  id='choice_1_47_1'    \/>\n\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='Non applicable'  id='choice_1_47_2'    \/>\n\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Non applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_48\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Allaitez-vous<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_48'>\n\t\t\t<li class='gchoice gchoice_1_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Oui'  id='choice_1_48_0'    \/>\n\t\t\t\t<label for='choice_1_48_0' id='label_1_48_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='Non'  id='choice_1_48_1'    \/>\n\t\t\t\t<label for='choice_1_48_1' id='label_1_48_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_2'>\n\t\t\t\t<input name='input_48' type='radio' value='Non applicable'  id='choice_1_48_2'    \/>\n\t\t\t\t<label for='choice_1_48_2' id='label_1_48_2' class='gform-field-label gform-field-label--type-inline'>Non applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_153\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">AVEZ-VOUS SOUFFERT OU SOUFFREZ-VOUS DE<\/div><\/li><li id=\"field_1_51\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Infarctus<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_51'>\n\t\t\t<li class='gchoice gchoice_1_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='Oui'  id='choice_1_51_0'    \/>\n\t\t\t\t<label for='choice_1_51_0' id='label_1_51_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='Non'  id='choice_1_51_1'    \/>\n\t\t\t\t<label for='choice_1_51_1' id='label_1_51_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_53\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Angine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_53'>\n\t\t\t<li class='gchoice gchoice_1_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Oui'  id='choice_1_53_0'    \/>\n\t\t\t\t<label for='choice_1_53_0' id='label_1_53_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='Non'  id='choice_1_53_1'    \/>\n\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_165\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Infection du coeur (endocardite)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_165'>\n\t\t\t<li class='gchoice gchoice_1_165_0'>\n\t\t\t\t<input name='input_165' type='radio' value='Oui'  id='choice_1_165_0'    \/>\n\t\t\t\t<label for='choice_1_165_0' id='label_1_165_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_165_1'>\n\t\t\t\t<input name='input_165' type='radio' value='Non'  id='choice_1_165_1'    \/>\n\t\t\t\t<label for='choice_1_165_1' id='label_1_165_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_50\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Chirurgie pour poser ou r\u00e9parer valve\/valvole<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_50'>\n\t\t\t<li class='gchoice gchoice_1_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Oui'  id='choice_1_50_0'    \/>\n\t\t\t\t<label for='choice_1_50_0' id='label_1_50_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='Non'  id='choice_1_50_1'    \/>\n\t\t\t\t<label for='choice_1_50_1' id='label_1_50_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_57\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >H\u00e9mophilie<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_57'>\n\t\t\t<li class='gchoice gchoice_1_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Oui'  id='choice_1_57_0'    \/>\n\t\t\t\t<label for='choice_1_57_0' id='label_1_57_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Non'  id='choice_1_57_1'    \/>\n\t\t\t\t<label for='choice_1_57_1' id='label_1_57_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_143\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Saignement prolong\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_143'>\n\t\t\t<li class='gchoice gchoice_1_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Oui'  id='choice_1_143_0'    \/>\n\t\t\t\t<label for='choice_1_143_0' id='label_1_143_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='Non'  id='choice_1_143_1'    \/>\n\t\t\t\t<label for='choice_1_143_1' id='label_1_143_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_59\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >An\u00e9mie<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_59'>\n\t\t\t<li class='gchoice gchoice_1_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='Oui'  id='choice_1_59_0'    \/>\n\t\t\t\t<label for='choice_1_59_0' id='label_1_59_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='Non'  id='choice_1_59_1'    \/>\n\t\t\t\t<label for='choice_1_59_1' id='label_1_59_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_166\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Haute pression<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_166'>\n\t\t\t<li class='gchoice gchoice_1_166_0'>\n\t\t\t\t<input name='input_166' type='radio' value='Oui'  id='choice_1_166_0'    \/>\n\t\t\t\t<label for='choice_1_166_0' id='label_1_166_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_166_1'>\n\t\t\t\t<input name='input_166' type='radio' value='Non'  id='choice_1_166_1'    \/>\n\t\t\t\t<label for='choice_1_166_1' id='label_1_166_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_167\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Basse pression<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_167'>\n\t\t\t<li class='gchoice gchoice_1_167_0'>\n\t\t\t\t<input name='input_167' type='radio' value='Oui'  id='choice_1_167_0'    \/>\n\t\t\t\t<label for='choice_1_167_0' id='label_1_167_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_167_1'>\n\t\t\t\t<input name='input_167' type='radio' value='Non'  id='choice_1_167_1'    \/>\n\t\t\t\t<label for='choice_1_167_1' id='label_1_167_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_60\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Autre probl\u00e8me sanguin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_60'>\n\t\t\t<li class='gchoice gchoice_1_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Oui'  id='choice_1_60_0'    \/>\n\t\t\t\t<label for='choice_1_60_0' id='label_1_60_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='Non'  id='choice_1_60_1'    \/>\n\t\t\t\t<label for='choice_1_60_1' id='label_1_60_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_61\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_154\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">AUTRES PROBL\u00c8MES DE SANT\u00c9<\/div><\/li><li id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rhumes fr\u00e9quents ou sinusite<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_63'>\n\t\t\t<li class='gchoice gchoice_1_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Oui'  id='choice_1_63_0'    \/>\n\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='Non'  id='choice_1_63_1'    \/>\n\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_64\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tuberculose ou probl\u00e8me pulmonaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_64'>\n\t\t\t<li class='gchoice gchoice_1_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='Oui'  id='choice_1_64_0'    \/>\n\t\t\t\t<label for='choice_1_64_0' id='label_1_64_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='Non'  id='choice_1_64_1'    \/>\n\t\t\t\t<label for='choice_1_64_1' id='label_1_64_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_65\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Trouble digestif<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_65'>\n\t\t\t<li class='gchoice gchoice_1_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='Oui'  id='choice_1_65_0'    \/>\n\t\t\t\t<label for='choice_1_65_0' id='label_1_65_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='Non'  id='choice_1_65_1'    \/>\n\t\t\t\t<label for='choice_1_65_1' id='label_1_65_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_66\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ulc\u00e8re de l\u2019estomac<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_66'>\n\t\t\t<li class='gchoice gchoice_1_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Oui'  id='choice_1_66_0'    \/>\n\t\t\t\t<label for='choice_1_66_0' id='label_1_66_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='Non'  id='choice_1_66_1'    \/>\n\t\t\t\t<label for='choice_1_66_1' id='label_1_66_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_67\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Probl\u00e8me du foie (h\u00e9patite : virus A, B, C, cirrose)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_67'>\n\t\t\t<li class='gchoice gchoice_1_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='Oui'  id='choice_1_67_0'    \/>\n\t\t\t\t<label for='choice_1_67_0' id='label_1_67_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='Non'  id='choice_1_67_1'    \/>\n\t\t\t\t<label for='choice_1_67_1' id='label_1_67_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_68\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Troubles r\u00e9naux<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_68'>\n\t\t\t<li class='gchoice gchoice_1_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Oui'  id='choice_1_68_0'    \/>\n\t\t\t\t<label for='choice_1_68_0' id='label_1_68_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='Non'  id='choice_1_68_1'    \/>\n\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_145\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Diab\u00e8te<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_145'>\n\t\t\t<li class='gchoice gchoice_1_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Oui'  id='choice_1_145_0'    \/>\n\t\t\t\t<label for='choice_1_145_0' id='label_1_145_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='Non'  id='choice_1_145_1'    \/>\n\t\t\t\t<label for='choice_1_145_1' id='label_1_145_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_70\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Troubles thyro\u00efdiens<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_70'>\n\t\t\t<li class='gchoice gchoice_1_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='Oui'  id='choice_1_70_0'    \/>\n\t\t\t\t<label for='choice_1_70_0' id='label_1_70_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='Non'  id='choice_1_70_1'    \/>\n\t\t\t\t<label for='choice_1_70_1' id='label_1_70_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_69\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Maladie de la peau<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_69'>\n\t\t\t<li class='gchoice gchoice_1_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='Oui'  id='choice_1_69_0'    \/>\n\t\t\t\t<label for='choice_1_69_0' id='label_1_69_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='Non'  id='choice_1_69_1'    \/>\n\t\t\t\t<label for='choice_1_69_1' id='label_1_69_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_71\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Probl\u00e8mes oculaires (yeux)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_71'>\n\t\t\t<li class='gchoice gchoice_1_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Oui'  id='choice_1_71_0'    \/>\n\t\t\t\t<label for='choice_1_71_0' id='label_1_71_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='Non'  id='choice_1_71_1'    \/>\n\t\t\t\t<label for='choice_1_71_1' id='label_1_71_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_74\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Prenez-vous des biphosphonates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_74'>\n\t\t\t<li class='gchoice gchoice_1_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Oui'  id='choice_1_74_0'    \/>\n\t\t\t\t<label for='choice_1_74_0' id='label_1_74_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='Non'  id='choice_1_74_1'    \/>\n\t\t\t\t<label for='choice_1_74_1' id='label_1_74_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_75\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous des proth\u00e8ses articulaires (hanche, genou, autre...)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_75'>\n\t\t\t<li class='gchoice gchoice_1_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Oui'  id='choice_1_75_0'    \/>\n\t\t\t\t<label for='choice_1_75_0' id='label_1_75_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='Non'  id='choice_1_75_1'    \/>\n\t\t\t\t<label for='choice_1_75_1' id='label_1_75_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_72\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ost\u00e9oporose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_72'>\n\t\t\t<li class='gchoice gchoice_1_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Oui'  id='choice_1_72_0'    \/>\n\t\t\t\t<label for='choice_1_72_0' id='label_1_72_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='Non'  id='choice_1_72_1'    \/>\n\t\t\t\t<label for='choice_1_72_1' id='label_1_72_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_73\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'>Si oui, pr\u00e9vention \/ traitements<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_1_73' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_146\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00c9pilepsie<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_146'>\n\t\t\t<li class='gchoice gchoice_1_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='Oui'  id='choice_1_146_0'    \/>\n\t\t\t\t<label for='choice_1_146_0' id='label_1_146_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='Non'  id='choice_1_146_1'    \/>\n\t\t\t\t<label for='choice_1_146_1' id='label_1_146_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_76\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Trouble ou maladie du syst\u00e8me nerveux<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_76'>\n\t\t\t<li class='gchoice gchoice_1_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Oui'  id='choice_1_76_0'    \/>\n\t\t\t\t<label for='choice_1_76_0' id='label_1_76_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='Non'  id='choice_1_76_1'    \/>\n\t\t\t\t<label for='choice_1_76_1' id='label_1_76_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_77\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_77'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_1_77' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_78\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Probl\u00e8mes d&#039;ordre psychologique ou \u00e9motionnel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_78'>\n\t\t\t<li class='gchoice gchoice_1_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Oui'  id='choice_1_78_0'    \/>\n\t\t\t\t<label for='choice_1_78_0' id='label_1_78_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='Non'  id='choice_1_78_1'    \/>\n\t\t\t\t<label for='choice_1_78_1' id='label_1_78_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_169\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_169'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_1_169' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_168\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous re\u00e7u un diagnostic d&#039;autisme, de TDA ou autre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_168'>\n\t\t\t<li class='gchoice gchoice_1_168_0'>\n\t\t\t\t<input name='input_168' type='radio' value='Oui'  id='choice_1_168_0'    \/>\n\t\t\t\t<label for='choice_1_168_0' id='label_1_168_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_168_1'>\n\t\t\t\t<input name='input_168' type='radio' value='Non'  id='choice_1_168_1'    \/>\n\t\t\t\t<label for='choice_1_168_1' id='label_1_168_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_79\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_79'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_80\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00c9tourdissements, \u00e9vanouissements<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_80'>\n\t\t\t<li class='gchoice gchoice_1_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Oui'  id='choice_1_80_0'    \/>\n\t\t\t\t<label for='choice_1_80_0' id='label_1_80_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='Non'  id='choice_1_80_1'    \/>\n\t\t\t\t<label for='choice_1_80_1' id='label_1_80_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Maux d\u2019oreilles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_81'>\n\t\t\t<li class='gchoice gchoice_1_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Oui'  id='choice_1_81_0'    \/>\n\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='Non'  id='choice_1_81_1'    \/>\n\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_82\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rhume des foins<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_82'>\n\t\t\t<li class='gchoice gchoice_1_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Oui'  id='choice_1_82_0'    \/>\n\t\t\t\t<label for='choice_1_82_0' id='label_1_82_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='Non'  id='choice_1_82_1'    \/>\n\t\t\t\t<label for='choice_1_82_1' id='label_1_82_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_83\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Asthme<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_83'>\n\t\t\t<li class='gchoice gchoice_1_83_0'>\n\t\t\t\t<input name='input_83' type='radio' value='Oui'  id='choice_1_83_0'    \/>\n\t\t\t\t<label for='choice_1_83_0' id='label_1_83_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_83_1'>\n\t\t\t\t<input name='input_83' type='radio' value='Non'  id='choice_1_83_1'    \/>\n\t\t\t\t<label for='choice_1_83_1' id='label_1_83_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_84\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Fumez-vous<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_84'>\n\t\t\t<li class='gchoice gchoice_1_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Oui'  id='choice_1_84_0'    \/>\n\t\t\t\t<label for='choice_1_84_0' id='label_1_84_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='Non'  id='choice_1_84_1'    \/>\n\t\t\t\t<label for='choice_1_84_1' id='label_1_84_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_84_2'>\n\t\t\t\t<input name='input_84' type='radio' value='\u00c0 l&#039;occasion'  id='choice_1_84_2'    \/>\n\t\t\t\t<label for='choice_1_84_2' id='label_1_84_2' class='gform-field-label gform-field-label--type-inline'>\u00c0 l'occasion<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_101\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Consommez-vous des drogues<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_101'>\n\t\t\t<li class='gchoice gchoice_1_101_0'>\n\t\t\t\t<input name='input_101' type='radio' value='Oui'  id='choice_1_101_0'    \/>\n\t\t\t\t<label for='choice_1_101_0' id='label_1_101_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_1'>\n\t\t\t\t<input name='input_101' type='radio' value='Non'  id='choice_1_101_1'    \/>\n\t\t\t\t<label for='choice_1_101_1' id='label_1_101_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_102\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Consommez-vous de l\u2019alcool<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_102'>\n\t\t\t<li class='gchoice gchoice_1_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='Peu ou pas'  id='choice_1_102_0'    \/>\n\t\t\t\t<label for='choice_1_102_0' id='label_1_102_0' class='gform-field-label gform-field-label--type-inline'>Peu ou pas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='Mod\u00e9r\u00e9ment'  id='choice_1_102_1'    \/>\n\t\t\t\t<label for='choice_1_102_1' id='label_1_102_1' class='gform-field-label gform-field-label--type-inline'>Mod\u00e9r\u00e9ment<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_2'>\n\t\t\t\t<input name='input_102' type='radio' value='Beaucoup'  id='choice_1_102_2'    \/>\n\t\t\t\t<label for='choice_1_102_2' id='label_1_102_2' class='gform-field-label gform-field-label--type-inline'>Beaucoup<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_103\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 ou subi des interventions chirurgicales autres que dentaires<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_103'>\n\t\t\t<li class='gchoice gchoice_1_103_0'>\n\t\t\t\t<input name='input_103' type='radio' value='Oui'  id='choice_1_103_0'    \/>\n\t\t\t\t<label for='choice_1_103_0' id='label_1_103_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_103_1'>\n\t\t\t\t<input name='input_103' type='radio' value='Non'  id='choice_1_103_1'    \/>\n\t\t\t\t<label for='choice_1_103_1' id='label_1_103_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_104\" class=\"gfield gfield--type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_104'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_1_104' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_85\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 subi des traitements de radioth\u00e9rapie et\/ou chimioth\u00e9rapie (tumeur)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_85'>\n\t\t\t<li class='gchoice gchoice_1_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='Oui'  id='choice_1_85_0'    \/>\n\t\t\t\t<label for='choice_1_85_0' id='label_1_85_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='Non'  id='choice_1_85_1'    \/>\n\t\t\t\t<label for='choice_1_85_1' id='label_1_85_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_86\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Infection transmise sexuellement (ITS)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_86'>\n\t\t\t<li class='gchoice gchoice_1_86_0'>\n\t\t\t\t<input name='input_86' type='radio' value='Oui'  id='choice_1_86_0'    \/>\n\t\t\t\t<label for='choice_1_86_0' id='label_1_86_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_86_1'>\n\t\t\t\t<input name='input_86' type='radio' value='Non'  id='choice_1_86_1'    \/>\n\t\t\t\t<label for='choice_1_86_1' id='label_1_86_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_87\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Porteur du virus HIV (s\u00e9ropositif)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_87'>\n\t\t\t<li class='gchoice gchoice_1_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Oui'  id='choice_1_87_0'    \/>\n\t\t\t\t<label for='choice_1_87_0' id='label_1_87_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='Non'  id='choice_1_87_1'    \/>\n\t\t\t\t<label for='choice_1_87_1' id='label_1_87_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_160' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_1_160' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-160' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_155\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">AVEZ-VOUS D\u00c9J\u00c0 EU UNE R\u00c9ACTION ALLERGIQUE AUX PRODUITS SUIVANTS<\/div><\/li><li id=\"field_1_90\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Latex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_90'>\n\t\t\t<li class='gchoice gchoice_1_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Oui'  id='choice_1_90_0'    \/>\n\t\t\t\t<label for='choice_1_90_0' id='label_1_90_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='Non'  id='choice_1_90_1'    \/>\n\t\t\t\t<label for='choice_1_90_1' id='label_1_90_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_91\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Aliments<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_91'>\n\t\t\t<li class='gchoice gchoice_1_91_0'>\n\t\t\t\t<input name='input_91' type='radio' value='Oui'  id='choice_1_91_0'    \/>\n\t\t\t\t<label for='choice_1_91_0' id='label_1_91_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_91_1'>\n\t\t\t\t<input name='input_91' type='radio' value='Non'  id='choice_1_91_1'    \/>\n\t\t\t\t<label for='choice_1_91_1' id='label_1_91_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_92\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Iode<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_92'>\n\t\t\t<li class='gchoice gchoice_1_92_0'>\n\t\t\t\t<input name='input_92' type='radio' value='Oui'  id='choice_1_92_0'    \/>\n\t\t\t\t<label for='choice_1_92_0' id='label_1_92_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_92_1'>\n\t\t\t\t<input name='input_92' type='radio' value='Non'  id='choice_1_92_1'    \/>\n\t\t\t\t<label for='choice_1_92_1' id='label_1_92_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_93\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Aspirine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_93'>\n\t\t\t<li class='gchoice gchoice_1_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Oui'  id='choice_1_93_0'    \/>\n\t\t\t\t<label for='choice_1_93_0' id='label_1_93_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='Non'  id='choice_1_93_1'    \/>\n\t\t\t\t<label for='choice_1_93_1' id='label_1_93_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_94\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sulfamid\u00e9s<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_94'>\n\t\t\t<li class='gchoice gchoice_1_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Oui'  id='choice_1_94_0'    \/>\n\t\t\t\t<label for='choice_1_94_0' id='label_1_94_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='Non'  id='choice_1_94_1'    \/>\n\t\t\t\t<label for='choice_1_94_1' id='label_1_94_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_95\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >P\u00e9niciline<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_95'>\n\t\t\t<li class='gchoice gchoice_1_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='Oui'  id='choice_1_95_0'    \/>\n\t\t\t\t<label for='choice_1_95_0' id='label_1_95_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='Non'  id='choice_1_95_1'    \/>\n\t\t\t\t<label for='choice_1_95_1' id='label_1_95_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_96\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Cod\u00e9ine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_96'>\n\t\t\t<li class='gchoice gchoice_1_96_0'>\n\t\t\t\t<input name='input_96' type='radio' value='Oui'  id='choice_1_96_0'    \/>\n\t\t\t\t<label for='choice_1_96_0' id='label_1_96_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_96_1'>\n\t\t\t\t<input name='input_96' type='radio' value='Non'  id='choice_1_96_1'    \/>\n\t\t\t\t<label for='choice_1_96_1' id='label_1_96_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_97\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Autres antibiotiques<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_97'>\n\t\t\t<li class='gchoice gchoice_1_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='Oui'  id='choice_1_97_0'    \/>\n\t\t\t\t<label for='choice_1_97_0' id='label_1_97_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='Non'  id='choice_1_97_1'    \/>\n\t\t\t\t<label for='choice_1_97_1' id='label_1_97_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_98\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Anesth\u00e9sie locale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_98'>\n\t\t\t<li class='gchoice gchoice_1_98_0'>\n\t\t\t\t<input name='input_98' type='radio' value='Oui'  id='choice_1_98_0'    \/>\n\t\t\t\t<label for='choice_1_98_0' id='label_1_98_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_98_1'>\n\t\t\t\t<input name='input_98' type='radio' value='Non'  id='choice_1_98_1'    \/>\n\t\t\t\t<label for='choice_1_98_1' id='label_1_98_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_99\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Autres allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_99'>\n\t\t\t<li class='gchoice gchoice_1_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Oui'  id='choice_1_99_0'    \/>\n\t\t\t\t<label for='choice_1_99_0' id='label_1_99_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='Non'  id='choice_1_99_1'    \/>\n\t\t\t\t<label for='choice_1_99_1' id='label_1_99_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_100\" class=\"gfield gfield--type-text gf_third_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_100'>Pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_1_100' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_162' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_1_162' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-162' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_138\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Votre enfant est-il en p\u00e9riode active de croissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_138'>\n\t\t\t<li class='gchoice gchoice_1_138_0'>\n\t\t\t\t<input name='input_138' type='radio' value='Oui'  id='choice_1_138_0'    \/>\n\t\t\t\t<label for='choice_1_138_0' id='label_1_138_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_138_1'>\n\t\t\t\t<input name='input_138' type='radio' value='Non'  id='choice_1_138_1'    \/>\n\t\t\t\t<label for='choice_1_138_1' id='label_1_138_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_138_2'>\n\t\t\t\t<input name='input_138' type='radio' value='Non applicable'  id='choice_1_138_2'    \/>\n\t\t\t\t<label for='choice_1_138_2' id='label_1_138_2' class='gform-field-label gform-field-label--type-inline'>Non applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_139\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Votre enfant semble-t-il avoir atteint sa p\u00e9riode de pubert\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_139'>\n\t\t\t<li class='gchoice gchoice_1_139_0'>\n\t\t\t\t<input name='input_139' type='radio' value='Oui'  id='choice_1_139_0'    \/>\n\t\t\t\t<label for='choice_1_139_0' id='label_1_139_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_139_1'>\n\t\t\t\t<input name='input_139' type='radio' value='Non'  id='choice_1_139_1'    \/>\n\t\t\t\t<label for='choice_1_139_1' id='label_1_139_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_139_2'>\n\t\t\t\t<input name='input_139' type='radio' value='Non applicable'  id='choice_1_139_2'    \/>\n\t\t\t\t<label for='choice_1_139_2' id='label_1_139_2' class='gform-field-label gform-field-label--type-inline'>Non applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_140\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Les menstruations ont-elles d\u00e9but\u00e9es<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_140'>\n\t\t\t<li class='gchoice gchoice_1_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='Oui'  id='choice_1_140_0'    \/>\n\t\t\t\t<label for='choice_1_140_0' id='label_1_140_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='Non'  id='choice_1_140_1'    \/>\n\t\t\t\t<label for='choice_1_140_1' id='label_1_140_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_140_2'>\n\t\t\t\t<input name='input_140' type='radio' value='Non applicable'  id='choice_1_140_2'    \/>\n\t\t\t\t<label for='choice_1_140_2' id='label_1_140_2' class='gform-field-label gform-field-label--type-inline'>Non applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_141\" class=\"gfield gfield--type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_141'>Si oui, depuis combien de temps<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_1_141' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_176\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Acceptation collecte d&#039;informations personnelles*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_176.1' id='input_1_176_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_176\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_176_1' >Par la pr\u00e9sente je donne mon consentement \u00e0 la collecte, \u00e0 l'utilisation et \u00e0 la divulgation de mes renseignements personnels par MON ORTHO SUR LE PLATEAU dans le but de fournir des services dentaires.<\/label><input type='hidden' name='input_176.2' value='Par la pr\u00e9sente je donne mon consentement \u00e0 la collecte, \u00e0 l&#039;utilisation et \u00e0 la divulgation de mes renseignements personnels par MON ORTHO SUR LE PLATEAU dans le but de fournir des services dentaires.' class='gform_hidden' \/><input type='hidden' name='input_176.3' value='2' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_176' tabindex='0'>En savoir plus sur notre <a href=\"https:\/\/monorthosurleplateau.ca\/politiqueconfidentialite.html\" target=\"_blank\" rel=\"noopener noreferrer\">Politique de confidentialit\u00e9<\/a><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Envoyer vos informations'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='sVKnyFdgxYS45YMVVMYWPg72t8bZ\/K3AjOPp6vU6jc5mOJzpAfdCP4XdK1VOQnt499C9qeU+k2HPMvyQle+FcmQGUrplSLTN5HqwcFrR2twx7PQ=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJ7XCIxNzYuMVwiOlwiNWE3MDcxNDM5NjFjNmRlM2M1MWRkYWFmNDhlZWIzN2ZcIixcIjE3Ni4yXCI6XCJiOTRlMTdhYjJiMWIyNmNmMzMwMDk3ZWU3MGQ4MWEzNlwiLFwiMTc2LjNcIjpcIjkwYmZhYzAzZjUzNjNkMjZmNWRhM2M4Yjg4NzE5ZGZmXCJ9IiwiYzdjNjcxMGQ3NjhiY2NmNjdhYTkyZWEzMDNkYmJkMjgiXQ==' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' 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